Alcohol is the most commonly used recreational drug in sub-Saharan Africa, where the majority of HIV cases are located. Uganda has one of the highest rates of per capita alcohol consumption in the world. Alcohol has a substantial impact on the sub-Saharan African HIV epidemic via increased risk for sexual transmission of HIV and decreased adherence to antiretroviral therapy (ART), which may lead to treatment failure. We have observed a high rate of self-reported natural recovery from hazardous drinking in the absence of alcohol treatment in a cohort of HIV positives initiating ART in Mbarara, Uganda. More than half (56%) of participants who reported hazardous drinking in the year prior to study entry and 70% of those who reported moderate drinking in the prior year reported that they had abstained from drinking alcohol in the prior 3 months. The majority of those who reported that they had stopped drinking remained abstinent throughout follow-up of up to three years. It is possible that decreases in self-reported alcohol consumption are due to under-report of current versus past alcohol use as a result of stigma associated with alcohol consumption or fear of losing access to ART. On the other hand, decreases may be due to real reductions in alcohol consumption concurrent with declining health, behavioral counseling conducted at the HIV clinic, or pressure from family, friends, and/or treatment supporters. We propose a prospective cohort study of 212 HIV positive alcohol consumers to quantify changes in alcohol consumption during the first year of HIV care. We have recently validated several biomarkers of heavy alcohol consumption-direct metabolites of alcohol that may be detected for extended periods of time after alcohol itself has left the body-and we propose to use the best of these measures as an adjunct to self-report and to estimate under-report of heavy alcohol consumption. We will conduct qualitative observations of HIV clinic sessions (n=60) in order to examine how alcohol reduction is approached in that setting. We will additionally examine reasons for changes in alcohol consumption in quantitative and qualitative studies, using prior clinic observations to inform this inquiry. The long-term goal of this study is to quantify changes in alcohol consumption during HIV care and to determine factors predictive of such change to inform future interventions to decrease alcohol consumption. This proposal is directly responsive to the NIAAA Five-Year Strategic Plan goal to identify biological and contextual social factors that contribute to changes in drinking behavior. PUBLIC HEALTH RELEVANCE: While alcohol consumption is a significant problem in sub-Saharan Africa, there are few interventions to reduce heavy drinking in resource-limited settings. This study will objectively measure changes in alcohol consumption and examine determinants of changes among HIV positives in HIV care in Uganda. This study will provide vital information about feasible and culturally appropriate ways to reduce heavy drinking in HIV positives in care. Such methods may also be applicable to wider medical settings such as primary care in resource-poor countries.